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Habitual shoulder dislocation: causes, symptoms, diagnosis, treatment
Last reviewed: 23.04.2024
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ICD-10 code
S43.0. Dislocation of the shoulder joint.
[What causes a habitual dislocation of the shoulder?
Sometimes repeated dislocations arise without special violence - it is enough to withdraw and rotate the shoulder outwards. For example, swinging the hand to hit the ball, trying to throw a stone, laying hands on the head, putting on clothes, combing, etc. Periodically dislocations of the shoulder can occur in a dream. Such dislocations are called habitual.
The development of the habitual dislocation of the shoulder can be facilitated by damage to the neurovascular bundle, the joint lip, fractures of the articular cavity of the scapula. But most often the habitual dislocation develops as a complication of traumatic anterior dislocation due to official mistakes: neglect of anesthesia or its inferiority, crude methods of correction, insufficient immobilization or lack of it, early physical activity. As a result, damaged tissues (capsule, ligaments and muscles surrounding the joint) heal by secondary tension with the formation of persistent scars, there is a muscle imbalance. The instability of the shoulder joint develops with the outcome in the habitual dislocation.
Symptoms of a habitual dislocation of the shoulder
Dislocations are repeated, as their frequency increases, the load necessary for their occurrence decreases, and the method for their elimination is simplified. As a result, the patient refuses medical assistance and eliminates dislocations alone or with the help of others. After repositioning, as a rule, the pain in the shoulder joint, which lasts for several hours, sometimes 1-2 days, is worried. We observed patients who had 500 or more dislocations, which occurred 1-3 times a day. Self-control of the shoulder is performed by the patient in various ways: by traction with a healthy arm over the dislocated shoulder, by tapping and rotating the dislocated arm, by traction over the dislocated arm, the hand of which is clamped between the patient's knees, etc.
Classification of habitual shoulder dislocation
According to G.P. Kotelnikova, instability of the shoulder joint should be divided into compensated and decompensated forms, and in the first three stages are distinguished: subclinical, light clinical and pronounced clinical manifestations. This graduation allows a more accurate assessment of the patient's condition and on the pathogenetic basis to select the optimal method of surgical treatment and a complex of subsequent rehabilitation therapy. In particular, at the stage of subclinical manifestations, conservative treatment is used, which, in the opinion of the researcher, prevents a transition to the next stage of the pathological process.
Diagnosis of habitual shoulder dislocation
Anamnesis
In the anamnesis - a traumatic dislocation of the shoulder, after which dislocations began to repeat without adequate load. Retrospective study of the treatment of primary trauma, as a rule, reveals a number of gross errors.
Examination and physical examination
With an external examination, the atrophy of the muscles of the deltoid and scapular regions is revealed; the configuration of the shoulder joint is not changed, but its functions are severely affected. The restriction of active external rotation of the shoulder is noted when it is withdrawn to 90 ° and the forearm is bent due to fear of dislocation (Weinstein's symptom) and passive rotation in the same position and for the same reason (Babich's symptom). A positive symptom of Stepanov is characteristic. It is checked in the same way as Weinstein's symptom, but with the difference that the patient is placed on the couch on his back. Carrying the rotation of the shoulders, the patient can not reach the rear of the hand of the sick arm to the surface on which it lies.
Attempting to pass the hand to the body passively with the active resistance of the patient on the side of the defeat is easy, on the healthy side - no (symptom of a decrease in the strength of the deltoid muscle). Raising the arms up and simultaneously deflecting them to the back reveals the limitation of these movements on the side of the lesion (the symptom of the "scissors"). There are a number of signs of habitual dislocation of the shoulder, described in detail in the monograph A.F. Krasnov and R.B. Akhmedzyanova "Dislocations of the shoulder" (1982).
Laboratory and instrumental research
With the help of electromyography, a decrease in the electrical excitability of the deltoid muscle is detected (Novotnova symptom).
On the roentgenogram of the shoulder joint, moderate osteoporosis of the head of the humerus is determined. Sometimes on its rear surface there is a depressed defect located behind the apex of the large tubercle. The defect is clearly visible on the axial radiograph. A similar but less pronounced defect can be detected in the zone of the anterior margin of the articular cavity of the scapula.
Treatment of habitual shoulder dislocation
Conservative treatment of habitual dislocation of the shoulder
Patients with a habitual dislocation of the shoulder should be operated on, since conservative methods of treating the habitual dislocation of the shoulder do not give success.
Surgical treatment of habitual dislocation of the shoulder
There are more than 300 ways of surgical treatment of the habitual dislocation of the shoulder. All interventions can be divided into five main groups, not counting methods that have only historical significance. We give these groups with an illustration of each (1-2 methods, which have received the greatest distribution).
Operations on the capsule of the joint are the ancestors of the interventions with the usual dislocation of the shoulder, during which surgeons excised the excess capsule with subsequent corrugation and suturing.
Bankart (1923) noted that with a habitual dislocation of the shoulder, the anterior margin of the cartilaginous lip is detached from the osseous edge of the articular cavity of the scapula, and suggested the following method of surgical treatment. Front access cut off the apex of the beak-like process and lower the attached muscles to it, opening the shoulder joint. Then, silk transossal sutures fix the torn edge of the cartilaginous lip to its original position. The capsule of the joint is sutured, forming a duplication, over which the ends of the dissected earlier tendon of the subscapular muscle are stitched. Transcutaneously sew the tip of the beak-shaped scapula, and then overlap the skin. Complete surgical intervention with gypsum immobilization.
Operation by the Putti-Plyatt method is a simpler intervention from a technical point of view. Access to the joint is similar to the previous operation, but the dissection of the tendon of the scapular muscle and the capsule is made by incompatible cuts with subsequent separation of these formations from each other. Stitches are imposed with strong inner rotation of the shoulder, creating a duplicate capsule, and anterior to it - the duplication of the tendon of the scapular muscle.
In our country, these operations have not found wide application because of relapses: their frequency fluctuates in the first case from 1 to 15%, and with the second intervention - up to 13.6%.
Operations to create ligaments that fix the head of the shoulder. This group of operations - the most popular and numerous, has about 110 options. Most surgeons used the tendon of the long head of the biceps muscle to stabilize the shoulder joint. However, in techniques where the tendon was crossed during the creation of the ligament, a significant number of unsatisfactory results were noted. The researchers attributed this to a disruption in the nutrition of the crossed tendon, its degeneration and loss of strength.
A.F. Krasnov (1970) proposed a method of surgical treatment of the habitual dislocation of the shoulder, which lacks this shortcoming. The anterior zone of the intertubercular sulcus is exposed by anterior incision. Isolate and take on the holder of the tendon of the long head of the biceps muscle. From the inside, a part of a large tubercle is cut and deviated to the outside in the form of a leaf. Under it, form a vertical groove with oval ends, into which the tendon of the long head is transferred. The bones are laid in place and fixed with transossal sutures. Thus, the intrasseous tendon is subsequently intimately coalesced with the surrounding bone and forms a kind of round hip ligament, becoming one of the main components holding the shoulder from subsequent dislocations.
After the operation, a plaster bandage is applied for 4 weeks.
The operation was performed by more than 400 patients, followed by 25 years, only 3.3% of them had relapses. A retrospective study of the causes of relapse showed that to create a ligament, degenerative-altered, thinned, deflected tendons were taken, which were torn in case of repeated trauma.
To avoid such a cause of relapse, A.F. Krasnov and A.K. Polyhikhin (1990) proposed to strengthen the tendon of the biceps muscle. It is implanted in canned alco-alchohol. The allograft is sutured to the tendon throughout the entire length, and the lower end is immersed in the muscular abdomen of the biceps, and only then the strengthened tendon is moved under the sash.
Operations on bones. These surgeries involve the restoration of bone defects or the creation of arthritis - additional bone abutments, protrusions that limit the mobility of the head of the humerus. A convincing example of such techniques can be the Eden operation (1917) or its version, proposed by Andina (1968).
In the first case, take an autograft from the crest of the tibia and tightly insert it into a depression created in the anterior part of the neck of the scapula so that the end of the transplanted bone is 1-1.5 cm above the articular cavity.
Andina took the transplant from the wing of the ilium, sharpened its lower end and inserted the scapula into the neck. The upper smoothed end faces anteriorly and serves as an obstacle to the displacement of the head of the humerus.
Another group of operations on the bones is a subcapital rotational osteotomy, which later limits the external rotation of the shoulder and reduces the possibility of dislocation.
Lack of all operations on the bones - limitation of shoulder joint function.
Operations on the muscles involve changing the length of the muscles and eliminating muscle imbalance. An example is the Menguson-Stack operation, which consists in transplanting the scapular muscle to a large tubercle in order to limit shoulder retraction and external rotation. Restriction of the last two movements by 30-40% reduces the risk of dislocation of the shoulder, but still relapses occur in 3.91% of operated patients.
F.F. Andreev in 1943 proposed the following operation. Cut off part of the coracoid process with attached muscles. This musculoskeletal component is carried under the tendon of the subscapular muscle and sewn to the same place. In the modification of Boychev move also the outer part of the small pectoral muscle. Relapses in the Andreev-Boychev procedure were noted in only 4.16% of patients.
Combined operations are interventions that combine the techniques of different groups. The most famous was the operation of V.T. Weinstein (1946).
The anterior incision is dissected in the projection of the interthybaric sulcus by soft tissues and the capsule of the shoulder joint. Isolate and divert the tendon of the long head of the biceps arm muscle outward. Produce a maximum rotation of the shoulder before the appearance of a small tubercle in the wound. The abdominal muscle fastened here for 4-5 cm, beginning from the tubercle, is longitudinally cut. Then the upper fascicle is crossed at the small tubercle, and the lower one at the end of the longitudinal incision. Under the severed, remaining small tubercle stump of the scapula muscle, the tendon of the long head of the biceps arm muscle is attached and fixed with a U-shaped seam, and the stump is stitched with the upper end of the subscapular muscle. After the operation, apply a soft bandage in the adjusted position of the arm for 10-12 days. The frequency of relapses, according to various authors, ranges from 4.65 to 27.58%.
The same group can include the operation of Yu.M. Sverdlov (1968), developed at CITO them. N.N. Priorov: the tenodesis of the tendon of the long head of the biceps arm muscle is combined with the creation of an additional autoplastic ligament fixing the head of the shoulder. Make an anterior incision from the coracoid process along the projection of the intercampa groove. The isolated tendon of the long bicep head is removed to the outside. From the tendons attached to the coracoid appendage of muscles, cut out a flap 7x2 cm in size by the base to the top. The arising defect is sewn. The catgut flap is sewn as a tube. The shoulder is retracted to 90 ° and rotated as much as possible outside. Inside of the small tubercle, the capsule of the joint is opened. In the neck of the humerus, a longitudinal groove is made by the chisel, a newly created bunch is placed in it and sutured to the outer edge of the capsule of the joint, and below it to the humerus. The inner sheet of the capsule is stitched with the outer one.
The inter-hump furrow is cleaned, a lot of small holes are drilled and a tendon of the long head of the biceps muscle is laid in it, which is pulled downwards and fixed with silk transossal sutures. Below the overstretched tendon is stitched in the form of a duplicate, and then layer-by-layer wound is sutured. Apply a plaster bandage for 4 weeks.
In the presence of an impression defect of the head of the humerus, surgical intervention is performed according to the method of R.B. Akhmedzyanova (1976) bone autoplastic by the type of "house roof".
Summarizing the section on the surgical treatment of habitual shoulder dislocation, we believe that choosing the optimal method is a difficult decision. The difficulty is that the results are in most cases evaluated according to the researcher's data (which, of course, will have better results) and one test for relapses. And this, though important, but not the only and not the main indicator. For example, the combined operation of Lange - a combination of operations ZHden and Megnusson-Stack - gives only 1.06-1.09% of relapses. However, after operations on bones and muscles separately, and even more so in combination (the Lange method), stiffness in the shoulder joint often develops and, of course, there will be no recurrence of the dislocation.
Unsafe and those interventions when it is necessary (without special evidence) to open the shoulder joint.
We will not refute the standard standard on duty, that the choice of method should be individual in each particular case and that the method that the surgeon has perfect is good. All this is so. But how can we find the optimal method in this case? To choose an acceptable method of surgical treatment for a particular patient and to obtain favorable results, the following conditions are necessary.
- Exact diagnosis of the pathology of the shoulder joint:
- type of dislocation - anterior, lower, posterior;
- whether there are intra-articular lesions - detachment of the cartilaginous lip, impression imbalance of the head of the humerus, defect of the articular cavity of the scapula;
- whether there are extra-articular damages - a detachment of the cuff of tendons of rotators.
- The method should be technically simple, and surgical intervention - sparing, with a minimal proportion of trauma, physiological in relation to the ligament-capsular and muscular apparatus.
- The method should not presuppose the creation of restriction of movements in the shoulder joint.
- Compliance with the terms and volume of immobilization.
- Adequate complex treatment in the period of immobilization and after its elimination.
- Correct labor expertise.
It seems to us that the majority of the listed advantages are possessed by the method of the AF operation. Krasnov (1970). It is technically simple, sparing and highly effective for long-term results. The 35-year experience of observation and surgical treatment of more than 400 patients showed that the shoulder joint function was preserved in all cases, and relapses amounted to only 3.3%.